Why did Jeffrey Williams die?

Jeannie Williams and her 11-year-old son, Jeffrey, are settling in after driving up from the family farm outside Rock Hill. It is a little before 10 on a rainy Friday evening in early June. They plan to pick up Jeffrey’s older sister the following morning from a weeklong Christian youth camp.

Jeffrey snuggles beneath the covers of the king-size bed, wearing his plaid pajamas. Jeannie later told her family she remembers sitting beside him, talking with her husband over the phone. She tells him goodnight, then begins her Bible study.

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Suddenly, she feels nauseated and confused. She rushes to the bathroom. She is so dizzy, she has to sit on the toilet. The last thing she remembers thinking is: I have to get my phone to call someone.

When a housekeeper finds them more than 14 hours later, around 12:25 the next afternoon, Jeffrey is dead in the bed. Jeannie, 49, is near death, lying unconscious on the bathroom floor, still in her clothes from the day before.

“Please hurry!” a hotel clerk pleads in a chilling call to 911. “This just happened to us.”

Less than two months earlier in the same room on the second floor of the Best Western, Daryl and Shirley Jenkins of Longview, Wash., died overnight in much the same way.

But despite the alarming circumstances of the first deaths – two bodies in a hotel room without any evidence of foul play – there is no indication that officials in Boone or anyone in the state’s medical examiner system acted with urgency to understand what happened.

Daryl and Shirley’s son and daughter immediately suspected carbon monoxide and left for Boone that afternoon. They said they talked about the possibility of poisoning with the medical examiner, the hotel, police. Still, the investigation moved at a fatally slow pace.

A toxicology test for carbon monoxide takes about 15 minutes to complete. After Daryl and Shirley died, it took the state 40 days to finish just one of the tests.

It was only after Jeffrey’s death that authorities recognized a public health hazard and evacuated the Best Western. A hazardous materials team discovered carbon monoxide spewing from the swimming pool water heater at levels so high in one location they worried it would ruin their detection equipment.

Room 225 was a death chamber.

Holding someone accountable

Three people died. Another person suffered debilitating injuries. Who is to blame?

A prosecutor is now reviewing evidence police compiled during a six-month investigation and will decide after the new year whether to seek criminal charges.

Both families have hired attorneys and are expected to file civil lawsuits. Possible targets include the hotel, Boone authorities, as well as any person or company that worked on the swimming pool heating system.

The Williams family wants to hold another party accountable: North Carolina’s medical examiner system.

Jeffrey’s death exposed faults within the system that the Observer first reported in 2001. The state pledged then to fix the problems but didn’t. Even now, the chief medical examiner describes having to rely on “basically volunteers” to investigate unexplained deaths in North Carolina.

The state knows medical examiners don’t go to most death scenes. It knows some don’t even view the bodies. It knows they sometimes provide inadequate investigative background about deaths.

If there had been a more vigilant investigation into why Daryl and Shirley died, Jeffrey might be alive today, and Jeannie Williams might not be facing health problems for the rest of her life.

The night Daryl and Shirley died

The multiple failures that led to that night in June can best be explained by stepping back to Sunday, April 14, when Daryl and Shirley Jenkins checked into the Best Western Plus Blue Ridge Plaza.

High school sweethearts, married 53 years, they had come from across the country to visit cousins in the community of Todd, about 20 minutes north of Boone on the South Fork of the New River.

Though news accounts after their deaths described them as elderly, family members did not think of them that way. Daryl, 73, was a retired counselor who had recently taken up snowboarding; Shirley, 72, a former office manager, was known for her distinctive laugh. They loved to travel.

They had been to the Blue Ridge Mountains once before, in September 2011, and stayed at the same Best Western. With them again on this trip were Shirley’s brother, Gary Watts, and his wife, Patsye. They drove up from the Atlanta airport Sunday and had an uneventful first night. They spent most of Monday seeing relatives.

After dinner at Cracker Barrel, the couples returned to the hotel around 8 and agreed to meet Tuesday morning for breakfast.

Daryl and Shirley never showed up.

Worried, Gary and Patsye asked if the hotel would check on them.

Shortly after 10 a.m. on April 16, a housekeeper entered the room. Shirley was lying on the carpet near the door, dressed in her pink and white nightgown. Daryl was lying nearby in the empty hot tub.

Frantic, the housekeeper called the front desk. The clerk called 911, and Patsye and Gary Watts raced to the room.

Patsye said they thought Shirley might still be alive, so Shirley’s brother got down on the floor and performed CPR. A health inspector, who happened to be in the hotel that morning on a routine inspection, jumped over Shirley’s body and began doing chest compressions on Daryl.

Over the next 53 days, authorities at multiple levels missed opportunities to protect the public, beginning when the bodies were first discovered and no one tested the room for carbon monoxide.

Firefighters looked around, from the fireplace on one wall to the hot tub on the other, and the fire chief said they didn’t find any obvious hazards. At the time, the town’s fire engines were not equipped with monitors to check for deadly gas. (They have since been added.) The department’s heavy-rescue truck had a monitor, but no one sent for it.

It was not their job, the fire chief said, to determine the cause of the deaths. That was the job of the medical examiner.

Clues to the deaths in Room 225

Deaths that are sudden, unexplained, accidental or violent are usually referred to medical examiners for investigation. So, a call went out to Dr. Brent Hall.

Hall, 53, is well-known in and around Boone. He was medical examiner for Watauga and four other counties. Like most of the state’s medical examiners, he had another full-time job. He works as a private pathologist, diagnosing disease and performing autopsies.

As a medical examiner for 20 years, he worked closely with emergency responders and would occasionally have pizza delivered to the medics, said Craig Sullivan, director of the privately owned Watauga Medics. “I’ve always thought a lot of him,” Sullivan said.

On the morning of April 16, Hall did not take what some experts say is one of the most crucial first steps in investigating a suspicious death.

He did not go to Room 225.

It’s a mistake not to go to the scene of a death, said Dr. Gregory Schmunk, president of the National Association of Medical Examiners. “To not go to the scene,” he said, “is just inviting potential problems. You’re just not getting the full picture.”

If Hall had driven to the hotel overlooking U.S. 421 and seen for himself where Daryl and Shirley collapsed, he might have gained a better sense of the mystifying circumstances.

He could have looked into the bathroom and seen a possible clue: Shirley had thrown up. Or talked with emergency responders who wondered whether something bad was in the air.

“If you have two people die in the same area with no obvious signs of foul play, it screams of an environmental cause,” said Timothy Rohrig, director of the nationally accredited Sedgwick County Regional Forensics Science Center in Wichita, Kan.

Boone Police Capt. Andy Le Beau, a 23-year veteran of police work, including several years in Charlotte in the mid-1990s, said he wasn’t surprised Hall didn’t show up.

Hall rarely went to death scenes, Le Beau said.

Not many medical examiners in North Carolina do.

System of volunteers

Unlike some states, North Carolina does not require medical examiners to go to the scene. An Observer analysis of state data shows that local medical examiners did not go to the scene in about 9 of every 10 deaths they investigated since 2001. They did not even view the body in about 1 of every 10 cases.

Dr. Deborah Radisch, the state’s chief medical examiner, has told the Observer it is law enforcement’s job to gather evidence at the scene and the medical examiner’s job to look over the body. “There is little that the ME can add at the scene, especially with current investigative technology and extensive scene photography,” Radisch said in January in an email response to questions on another Observer medical examiner story.

Some rural areas of North Carolina don’t have all the current investigative technology – Boone didn’t have gas monitors on its fire engines at the time.

Radisch, who declined to be interviewed for this story, said last year that medical examiners are “basically volunteers” performing a public service for a $100 fee for each death investigation.

North Carolina spends less than $1 per capita on its medical examiner system. Dr. Victor Weedn, a George Washington University professor who has studied nationally accredited systems, says states and counties should spend between $2.50 and $3.50 per capita.

If going to the scene were a requirement, Radisch said, the state would have even fewer medical examiners.

Not too long ago, Hall went to a greater percentage of death scenes than most of the state’s roughly 350 active medical examiners. In 2002, state data show, he went to the scene in nearly half of the 57 cases he investigated. Only six medical examiners with caseloads at least the size of Hall’s went more often.

Over time, the Observer learned, Hall began showing up less and less. Since 2010, he visited only two of 323 death scenes in cases he agreed to investigate.

As a medical examiner, Hall was called on to testify in court in criminal cases. On Jan. 28, 2010, he faced his own criminal charge.

Hall was stopped at 1:27 a.m. on a Thursday morning for driving 50 mph in a 35 mph zone on rural Meat Camp Road not far from his house, according to court documents. The sheriff’s deputy who pulled him over wrote in an affidavit that she detected a strong odor of alcohol and asked Hall to perform field sobriety tests. She said he performed poorly, so she arrested him.

Court documents show that Hall’s blood alcohol level was 0.19 – more than twice the legal limit. As required by law, he underwent a substance abuse assessment.

Because Hall and local prosecutors worked together on criminal cases, a special prosecutor was brought in to try the case. In May 2011, Hall was found guilty in District Court of speeding and driving while intoxicated. The judge sentenced him to 30 days in jail but suspended the sentence and placed Hall on six months’ unsupervised probation.

Hall appealed the conviction to Superior Court, where the trial has been postponed at least 15 times in more than 21/2 years. It is now scheduled Feb. 3.

The deadly signs of CO poisoning

Though Hall did not go to Room 225, he performed the autopsies on Daryl and Shirley.

Several outside medical examiners said signs of carbon monoxide poisoning should be evident in autopsies. Daryl and Shirley’s blood should have been bright red.

Hall did the autopsy on Shirley’s body on April 17, a day after they were found, and on Daryl’s body on April 18, and made no mention of the color of their blood. He said that Daryl had severe coronary disease and that both had mild to moderate fluid in their lungs and congestion. While those symptoms could be markers of carbon-monoxide poisoning, they also could be signs of heart disease or overdose.

If Hall wasn’t looking for carbon monoxide, he might have overlooked the discoloration, said Dr. Gregory Davis, assistant state medical examiner for Kentucky. “There’s an old saying in pathology,” Davis said, “If you’re not looking for it, you’re not going to find it.”

Hall at least considered carbon-monoxide poisoning, documents indicate. When he mailed samples of their blood to the Office of the Chief Medical Examiner in Raleigh, he asked that it be tested for alcohol and drugs – but also for carbon monoxide.

Hall then waited to get the results.

‘Something seriously wrong’

The hotel immediately closed off Room 225. But closing the room didn’t eliminate the danger.

Three days after the deaths, Serene Solinski hosted a 13th birthday party at the Best Western for her daughter Levi. It was Friday, April 19. The party began around 4 p.m. at the pool, followed by cake in the lobby. About 7:30 or 8 that night, Solinski said she and 10 girls checked into Room 325 for a sleepover.

Things started to go wrong about an hour later.

Levi complained she didn’t feel well, that the lights and noise bothered her. A little while later, another girl complained of the same symptoms. One girl threw up. Then another. And another.

All but one girl ended up going home. Solinski, her two daughters and the one friend spent the night. Solinski opened a window to air out the room, which she said felt “warm and stuffy and sick.” Le Beau speculated the open window may have saved them from serious harm.

Solinksi said she complained to the front desk several times. “I went down and told them that night that there is something seriously wrong. Ten little girls don’t fall out puking, passing out. That’s not normal. They need to get someone in there to inspect the room.”

No one at the hotel apparently made the connection with what happened earlier in the week one floor below in Room 225.

The toxicology requests

The samples of Daryl and Shirley’s blood had not even reached the toxicology lab in Raleigh by then.

It took five days for the specimens to get to the Office of the Chief Medical Examiner. Shirley’s arrived on April 22, Daryl’s on April 23.

The delay might not have mattered if Hall had completed the toxicology request forms that accompanied the blood. He did not do two things, the state said:

Hall did not ask that results be expedited.

He also did not fill out a section marked “pertinent history” in which medical examiners include background about a death – in this case, that two bodies were found in a hotel room. That information might have alerted toxicologists that the deaths were linked and that there could be a public health hazard.

In an email two years earlier, Radisch had reminded medical examiners about the importance of filling out that section.

The Observer reviewed toxicology request forms also submitted in April for carbon-monoxide testing and found that most included background information. Medical examiners wrote brief histories in 14 cases and the word “none” in one case. Hall left the section blank on each form he submitted.

None of the requests were marked “urgent.” Eight of the tests were completed in 10 or fewer days. Shirley’s test would take four times as long, 40 days, and Daryl’s, 47. Even the one case that had the word “none” under the history section took 19 days.

At the time, the state didn’t demand that local medical examiners fully complete the forms.

On separate four-page investigative reports that Hall sent to Raleigh the same week, he did note that Daryl and Shirley were found together in a hotel room with “no evidence of foul play.” But the reports would have been placed in the case files for later review by a pathologist, a state spokesman said, and it’s unlikely the toxicologist ever saw them.

In another unexplained decision, Hall indicated on the toxicology forms that the cause of each death might have been an overdose.

“OD?” he scribbled.

‘I just don’t feel right’

Police and medics who went to the scene said they did not suspect an overdose and were surprised Hall noted that on the forms. Le Beau, the police captain, said investigators bagged up prescription medication found in the hotel room and had it delivered to Hall, but that’s standard procedure.

Rather than an overdose, Patsye Watts said, a police investigator suggested what is sometimes called “broken-heart syndrome,” speculating that either Shirley or Daryl suffered a fatal heart attack and the other died from shock. The speculation took on the authenticity of fact the more it was shared. Two months later, after Jeffrey died, firefighters told the hazmat team the Jenkinses died of heart attacks, according to the hazmat incident report.

Watts said family members never believed that theory.

“If one had died, the other would have been able to handle it,” Watts said. “We as a family did not feel that they died of natural causes.”

She said the family suspected carbon monoxide.

Mark Brumbaugh, their attorney, said Daryl and Shirley’s son and daughter shared their suspicions with “anyone who would listen.”

The response, no matter whom they talked with, was always the same, he said: We’re waiting on toxicology results.

Sullivan, of Watauga Medics, said he and co-workers speculated for days over breakfast about what might have killed the couple, including carbon monoxide. “We discussed a little bit of everything,” Sullivan said. “We were all curious, waiting.”

There was enough uncertainty that the hotel didn’t rent the room for six weeks.

The lead police investigator also talked with Hall about carbon monoxide in the days immediately following the deaths, Le Beau said. He said Hall acknowledged the possibility, and also told the investigator that Daryl and Shirley each had enough heart disease to have killed them.

The investigator remained so perplexed, Le Beau said, she went online May 29, six weeks after Daryl and Shirley died, and requested the toxicology results.

Le Beau said she told him: “I just don’t feel right about it.”

Police have a record of the request, but the state said it never got it. A state spokesman said it wouldn’t have mattered – an online request doesn’t expedite toxicology tests. If police wanted the results sooner, they should have called.

That was 10 days before Jeffrey died.

Toxicology results not shared

It is the mission of the North Carolina medical examiner system to determine the cause of unexplained deaths and alert the public about health hazards. But the system doesn’t always operate with the same split-second efficiency you might expect after watching forensic police dramas on television.

It was not until Saturday, June 1 – 40 days after Shirley’s blood arrived – that her toxicology report was completed. It would take seven more days in Daryl’s case.

Medical examiners in three states known for their expertise in investigating deaths said it would be rare for their tests to take so long. Maryland turns around most tests within three to five days, said Bruce Goldfarb, executive assistant to the state’s chief medical examiner. In an urgent case, within 15 minutes. Others reported a two- to three-week turnaround.

North Carolina’s turnaround time depends on the complexity of the tests and the quality standards they require, said Ricky Diaz, spokesman for the N.C. Department of Health and Human Services, which oversees the medical examiner system. “Medical examiners can request a ‘stat’ test for the presence of carbon monoxide,” he said. “In those cases, the toxicology lab will expedite the test.”

After the test was completed in Shirley’s case, the state waited two days to notify Hall. Unless a request is expedited, Diaz said, the report is not emailed until normal business hours.

“A positive carbon-monoxide result, by itself, does not point to a potential threat or emergent situation,” he said. “Considering that the majority of positive carbon-monoxide tests are the result of house fires, car fires or suicides, additional facts are needed to reach that conclusion. The toxicology lab relies on the information it receives from the pathologist.”

Diaz said results were emailed to Hall on Monday, June 3.

Jeffrey and Jeannie would not check into the Best Western until Friday. There was still time to save them.

The biggest puzzle is whether Hall got the email, read it and did nothing. He has declined to comment.

Reopening Room 225

The breakdown in communication might not have been fatal if Room 225 had remained closed. But the Best Western reopened the room May 31, Le Beau said.

Why did the hotel manager think it was safe to reopen Room 225?

Attorney Paul Culpepper of Hickory, who represents hotel management, said the hotel consulted with police and had a contractor inspect the pool heater and the fireplace in the room. Damon Mallatere, whose company manages the hotel, declined to comment.

The hotel was under no legal obligation to keep the room closed.

Police said they did not have authority to close the room or shut down the hotel. Firefighters and medics said they did not. A state spokesman said there’s no single protocol for what a local medical examiner should do in the event of a potential threat to public safety.

The building inspector said he might have been able to shut down the hotel, but he would have needed evidence of a violation.

The evidence was in the toxicology report June 1, seven days before Jeffrey died.

That night, two people stayed in Room 225 and “had a pleasant stay, no issues,” Le Beau said. He speculated they escaped death because the swimming pool water heater wasn’t running, or wasn’t running often. The heater, he said, was controlled by a thermostat, but employees could manually adjust it based on the water temperature in the pool.

No one stayed in the room again until Jeannie and Jeffrey checked in six days later.

The day Jeffrey died

They arrived at the Best Western late in the evening on Friday, June 7. Their room smelled so much of cigarette smoke that around 9 p.m., Jeannie asked that they be moved.

The clerk offered to upgrade them to one of the hotel’s 11 luxury rooms, a family member said. It had a king-size bed, heart-shaped hot tub and gas fireplace.

Room 225.

Directly below them, as the pool heater worked to warm the water, it emitted a stream of deadly odorless gas that seeped into the room. Le Beau suspects an employee likely cranked up the thermostat. He said the same thing might have happened the night Daryl and Shirley Jenkins died.

Jeannie later told her family that she felt fine one moment, terrible the next.

She and Jeffrey planned to get up Saturday morning, eat breakfast, then drive about 30 minutes to Banner Elk, where Jeffrey’s sister, Breanne, 17, was at camp.

The three of them were very close. Jeannie home-schooled both children on the family farm outside Rock Hill, where they raised cows, horses, chickens and pigs. Breanne had just completed 11th grade; Jeffrey, fifth grade.

Later that day, they planned to hike at Grandfather Mountain. It would be a fun start to summer vacation.

But Jeannie and Jeffrey never showed up.

Breanne called her mother’s cellphone and didn’t get an answer, so she called her father. Jeff Williams owns Substation Concrete Services in Rock Hill and happened to be working in Hickory that morning, about an hour from Boone. He and Jeannie had met when they were studying at Mars Hill College near Asheville, where Jeff played defensive end on the football team.

Jeffrey was named for him.

Jeff called Jeannie and didn’t get an answer either, so he telephoned the Best Western. An employee went to look for them and told Jeff they had checked out.

Jeff then telephoned police who transferred him to the highway patrol. Had there been a car accident? Jeannie was always punctual and organized. It wasn’t like her to leave Breanne stranded.

He called the hotel a second time. After that call, the clerk realized they looked in the wrong room – the one that smelled of cigarettes. Jeannie and Jeffrey had moved into Room 225, where just two months earlier Daryl and Shirley also failed to show up for an appointment.

‘Please come help us’

Again, an employee was sent to check on Room 225. Again, there were two bodies.

The hotel clerk called 911 and went up to the room. A few minutes into the call, the dispatcher can be heard consulting with a colleague, then suddenly warning the clerk: “I’m going to need you to just go ahead and get out of that room.”

“Get out of the room!” the clerk called out. “Everybody get out of the room!”

Her voice breaking, the clerk then told the dispatcher “Oh, ma’am, this is awful, please.”

“You don’t understand,” the clerk said, and her voice broke a second time. “We just went through this.”

Once again, fire, police and medics rushed to the Best Western. This time, Sullivan, the owner of Watauga Medics, went, too. “We’re a pretty small town,” he said, “and bells and whistles were going off.”

Emergency responders carried Jeannie Williams out of the room and shut the door, leaving Jeffrey’s body on the bed.

Before re-entering the room, firefighters suited up in protective clothing and air masks. They tested for carbon monoxide and found potentially lethal levels. The hotel was evacuated.

Jeff Williams was driving toward Boone to find his wife and child when his phone rang: Jeannie was in the hospital; they didn’t know where Jeffrey was.

Then another call. Jeffrey was dead.

A standoff at the Best Western

It would take most of the afternoon and a standoff at the hotel before Jeff was allowed to see his son.

He and Jeannie are still too distressed to talk publicly about what happened at the Best Western. Jeff’s brother Darrell shared the story on behalf of the family. This is his account of the afternoon of June 8:

He said family members who were gathered at the hospital, where Jeannie was in intensive care, sent word to police that they wanted to see Jeffrey’s body. He said they were told that there might be a danger of contamination and that the body would not be removed from the hotel until a hazmat team determined what was wrong.

Hours passed. Jeff Williams grew more distraught. His brothers, Darrell and Dennis, decided to drive to the Best Western.

The parking lot was chaotic. Flashing lights. Yellow crime-scene tape. Fire. Police. Medics. Dozens of hotel guests wandering around, unable to get back into their rooms, some with a wedding to attend.

Darrell pleaded for Jeffrey’s body. He said a police officer told him that Hall, the medical examiner, had not given them permission to move it. When a medical examiner is investigating a death, only he or she can authorize the body’s removal.

A short while later, Jeffrey’s grandfather arrived from the hospital. Darrell said Jim Williams, 69, rarely shows a temper, but when they told him that Hall refused to release Jeffrey’s body for fear of contamination, he became furious. He said Hall was at the hospital, consulting on Jeannie’s injuries.

“If there was any real danger,” he said, “everyone in the ICU has already been exposed.”

Darrell called the hospital and asked to speak with Hall. By then, he said, police officers had gathered around them. He said his father got on the phone and warned Hall: “You either give the EMS the authority to remove Jeffrey’s body, or my sons are going to walk into that hotel and remove his body.”

Hall relented, and medics took Jeffrey’s body to the hospital.

About six hours after Jeff Williams learned that his 11-year-old son was dead, he finally saw him. He hugged Jeffrey, rested his cheek on Jeffrey’s cheek and laid with him.

“I love you,” he whispered. “I’ll miss you.”

He told Jeffrey to go be with Jesus, that he would see him again someday. Then he kissed his son goodbye.

Deadly levels of gas

Around 7 p.m., within an hour after Jeffrey’s body was taken away, four members of a hazmat team arrived at the Best Western.

They brought monitors capable of identifying and measuring 55 gases. After suiting up head to foot in protective clothing, they entered Room 225. They placed one gas identification pump on the nightstand and another near the bathroom sink.

Sunday afternoon, June 9, after the rest of the team arrived from Asheville, they checked the monitors. No poison.

They planned to test again for carbon monoxide, and also for chlorine gas, pesticides and possible residue from a methamphetamine or ricin lab.

Though a toxicology test eight days earlier revealed that Shirley died of carbon-monoxide poisoning, none of the investigators on the scene knew of those results. At 1:35 Sunday afternoon, they called the Office of the Chief Medical Examiner in Raleigh and asked that tests on Daryl and Shirley Jenkins be expedited.

When team members had surveyed the hotel earlier, they discovered that a metal pipe connected to the swimming pool water heater was severely corroded.

The 10-inch diameter pipe was supposed to remove carbon monoxide from the heater to the outdoors, but it had gaping rusted-out holes.

It was hidden in the dropped ceiling over the pool. Directly above was Room 225.

The hazmat team tested the air at various locations in and outside the hotel while the water heater was off. No poison.

A little after 4 p.m., they fired up the heater.

After 28 minutes, the level of carbon monoxide at one location was so high they stopped testing there to prevent damage to the sensor.

Four minutes later, they turned off the heater. It had been running for a little over half an hour. The level of carbon monoxide on a portable monitor placed on the nightstand inside Room 225 had soared to 343 parts per million, enough to make someone seriously ill. With longer exposure, the person would die.

The reading on a monitor outdoors near the room’s heating and air conditioning unit was nearly that high. And in Room 325 on the floor above, where the young girls became ill in April, the level of carbon monoxide was 56 parts per million, enough to make a person sick.

Further investigation revealed that there were two ways the poisonous gas could have entered Room 225, Le Beau said.

From inside the building, it rose through holes in the corroded exhaust pipe and up through a hole in the fireplace across from the bed.

From outside the building, the gas could have been sucked back inside through the room’s heating and air conditioning unit, or it could have seeped in through gaps around the unit.

Instead of being directed safely outdoors, the gas drifted and flowed through openings. The corroded pipe didn't hold it. A ventilation fan designed to pull it through the pipe to the outside wasn't working.

Still a little boy

The same day the hazmat team discovered the source of the carbon monoxide, Hall performed an autopsy on Jeffrey.

A written autopsy report typically includes clinical medical language, but it also provides a personal glimpse into the life of the deceased. Jeffrey was still a little boy, less than 5 feet tall and weighing 85 pounds. He wore braces. On his pajama top was a picture of a black dog and the words “North Pole 28 Challenge.”

Hall noted “red discoloration” in his organs and blood – the telltale sign of carbon-monoxide poisoning that experts said should have been evident during Daryl and Shirley’s autopsies.

Hall also noted vomit on Jeffrey’s pajama top, a side effect of carbon-monoxide exposure. He noted a bluish-purple discoloration beneath his fingernails, caused by a lack of oxygen.

Too much carbon monoxide diminishes a person’s ability to absorb oxygen, causing headaches, dizziness, vomiting and confusion as well as discoloration of fingernails, nostrils and lips. At extremely high doses, it can cause loss of consciousness or death within minutes, similar to suffocation.

The reason Jeannie Williams survived, her family believes, is because she collapsed beneath the exhaust fan in the bathroom.

Shortcuts to tragedy

No one knows for sure when the carbon monoxide began leaking into Room 225, or how many other people were poisoned.

Police said they heard from a few hotel guests who became sick in months past and suspected the flu. Two girls who attended the birthday party in Room 325 have possible side effects. Solinski said that her daughter’s eyesight is damaged and that another girl has violent headaches.

When the Best Western was built in 2000, original plans called for carbon-monoxide detectors in the 11 rooms with fireplaces, said Culpepper, the attorney who represents hotel management. Instead, he said, the contractor put in the wrong type of detectors, combustible gas monitors. The hotel didn’t discover the mistake, he said, until after the deaths.

An Observer investigation in June found multiple shortcuts and violations when the swimming pool water heater was installed in 2011. It was a used heater that hotel employees moved from a Sleep Inn hotel run by the same company, Appalachian Hospitality Management.

The employees were not licensed to do the work and did not get a permit or an inspection, in violation of the North Carolina Building Code. Not only did they install the heater improperly, they also did not put a carbon-monoxide detector nearby despite explicit warnings in the owner’s manual.

In February 2012, the hotel hired a company to convert the heater from propane to natural gas. The company applied for a permit, as required, and the town inspected and approved the work.

A town official declined to say whether an inspector examined the corroded exhaust pipe.

After Jeffrey died, investigators with a state licensing board discovered multiple unseen dangers in the heating system. They took 325 photographs that illustrate the hazards in frightening detail: pipes with rusted holes, different-sized pipes improperly joined together with tape, vents covered by insulation, gashes in the drywall of the equipment room.

Several gas lines appeared to have been modified, according to the Board of Examiners of Plumbing, Heating and Fire Sprinkler Contractors. In some places, the outer liner of the exhaust pipe had rusted away; in other places, the inner liner had deteriorated. An ice bucket was propped up under one pipe, apparently to catch condensation; a VHS videotape supported an elbow fitting on another pipe.

‘100 percent preventable’

Though carbon monoxide from the pool heater killed Jeffrey, Darrell Williams believes North Carolina’s medical examiner system is to blame for his death.

“It was 100 percent preventable and should have never happened,” Williams said. “The (state) medical examiner’s office was fully aware that there was carbon-monoxide poisoning involved in the Jenkinses’ deaths a week before Jeffrey was sent to his death in that room.”

He faulted Hall for failing to pinpoint carbon monoxide during the autopsies of Daryl and Shirley Jenkins.

Dr. Aldona Wos, the state secretary of health and human services, said in a written statement in June that the deaths “should have never happened.” She said she instructed her staff to work with local officials to prevent another such tragedy. She has declined repeated requests for interviews.

Diaz, the spokesman, said department officials reviewed what happened and do not believe any state employee erred. He said Hall was not a state employee.

The department is “actively pursuing opportunities for improvement and enhancement” of the medical examiner system, he said. He declined to be more specific except to say pathologists are now required to submit a written account of pertinent details about a death with any specimen mailed to the lab. If they don’t include the information, he said, the lab will contact the medical examiner before testing for anything other than alcohol.

In the past, filling out the section was considered “best practice.” The new policy making it a requirement took effect June 11, three days after Jeffrey died.

‘My side of the story’

Despite public outrage over the deaths, it was not until four days after Jeffrey died, on June 12, and only after prodding from the chief medical examiner, that Hall completed the three autopsy reports.

In the deaths of Daryl and Shirley Jenkins, Hall was paid $100 for each investigation and $1,000 for each autopsy. He also collected $1,100 for his work in Jeffrey’s death.

In a brief telephone conversation in September, Hall acknowledged that what happened has been difficult, but he declined to answer questions.

“If and when it goes to court,” he said, “I will tell my side of the story.”

Pressed to talk, Hall said: “I’d rather not say anything that I’m going to read in the paper tomorrow.” Approached last month by certified letter, Hall did not respond.

District Attorney Jerry Wilson said that during Hall’s 20 years as medical examiner in and around Boone, he gave the rural mountain communities the same expertise urban areas expect.

Wilson said Hall would hold him accountable in cases. “He would say, ‘Jerry, that’s just not right. That’s not what happened.’ He was such an excellent pathologist and such a fair pathologist, I hate to see him absolutely beat to death over a mistake.”

In Boone, some people believe Hall has been made a scapegoat.

Grief and a slow recovery

The night before they buried Jeffrey, Jeannie Williams was released from the hospital. She was brought to the church the next day in a wheelchair.

It was June 16, Father’s Day.

A screen in the sanctuary of Rock Hill’s First Baptist Church projected photographs of Jeffrey at various stages of his childhood doing things he loved – surf fishing at the beach with his father, practicing violin, cuddling with his mother.

Thanksgiving would have been Jeffrey’s 12th birthday.

With Christmas approaching, he would have been looking forward to this year’s big surprise from his grandparents. One year, Jim and Flora Williams took all the grandchildren to Busch Gardens in Tampa, Fla.; another year, they bought them a golf cart to drive around their property.

Each milestone without Jeffrey brings more anguish to his family.

“I ask that every one of your readers say a prayer for my brother, my sister-in-law, my niece and my family on Christmas,” Darrell Williams said.

He said Jeannie will face serious health problems for the rest of her life.

She can walk on her own, but she has a noticeable limp and has trouble climbing stairs. She finds it difficult to grip with her hands and perform simple tasks of dexterity.

“She has reached a plateau that we believe may be her full recovery,” he said. “The limited mobility will probably get exponentially worse with age.”

A bigger challenge, Darrell Williams said, is damage to her heart and brain caused by a lack of oxygen. “Jeannie was a very sharp and astute person before the accident,” he said. “However this accident has caused cognitive impairment.”

Jeannie no longer home-schools her daughter. Breanne is finishing her last year of high school at a private academy.

Lack of accountability

Police recently completed a six-month criminal investigation. Le Beau said it includes “the entire story” of what happened at the Best Western – from the installation and repair of the water heating system, to the response of fire, police and medics, to the role of the medical examiner.

It will be up to Wilson, the district attorney, whether evidence is presented to a grand jury. Wilson said a decision is not likely before January.

One possible charge is involuntary manslaughter. But a jury would have to find that someone acted recklessly and with disregard for the consequences, which legal experts said could be difficult to prove. They said the families would be more likely to prevail in civil court.

Attorneys have up to two years to file wrongful-death lawsuits.

“My clients obviously want to assure that something like this never happens again, at least in Boone,” said Brumbaugh of Longview, Wash., the attorney who represents Daryl and Shirley’s family. “Our primary focus is on the creation of the hazard that killed the Jenkinses in the first place, not so much the subsequent investigation.”

The State Board of Examiners is seeking injunctions against three people who did unregulated maintenance on the pool heating system, said Dale Dawson, the board’s executive director. He said the board also scheduled a “resolution conference” next week with a licensed professional who worked on the system, and the hearing could result in discipline, a letter of caution or license revocation.

The Best Western was cleared to reopen in mid-July. The pool area, which was off-limits to guests for several more months, is now again open but with a new electric heating system. The hotel also converted its fireplaces from gas to electricity.

For members of Daryl and Shirley’s family, the lack of accountability is infuriating.

“Our family continues to try to make sense of why my parents are dead, and why little Jeffrey Williams had to die too,” Kris Hauschildt, the Jenkinses’ daughter, wrote in a letter to Best Western CEO David Kong. “A large portion of what doesn’t make sense is why the Best Western in Boone was allowed to operate in such a way that three people are now dead – and then, as if that were not enough, it was subsequently allowed to re-open and is conducting business as usual as though nothing has happened.”

One thing has changed: The hotel said the room where her parents and Jeffrey died will not be rented out again. The number by the door has been removed.

Like the missing 13th floor in some buildings, at the Best Western in Boone, Room 225 no longer exists.